Category: pelvic inflammatory disease

A commissioned article in Lancet Infectious Diseases on July 9, 2017 highlights some of the major issues and challenges facing us in the growing global epidemic of sexually transmitted infections (STI). Authors Prof Mabhus Unemo et al summarise the key issues as follows:

WHO estimated that nearly 1 million people become infected every day with any of four curable sexually transmitted infections (STIs): chlamydia, gonorrhoea, syphilis, and trichomoniasis. Despite their high global incidence, STIs remain a neglected area of research.

In this Commission, we have prioritised five areas that represent particular challenges in STI treatment and control.

Chlamydia remains the most commonly diagnosed bacterial STI in high-income countries despite widespread testing recommendations, sensitive and specific non-invasive testing techniques, and cheap effective therapy. We discuss the challenges for chlamydia control and evidence to support a shift from the current focus on infection-based screening to improved management of diagnosed cases and of chlamydial morbidity, such as pelvic inflammatory disease.

The emergence and spread of antimicrobial resistance in Neisseria gonorrhoeae is globally recognised. We review current and potential future control and treatment strategies, with a focus on novel antimicrobials.

Bacterial vaginosis is the most common vaginal disorder in women, but current treatments are associated with frequent recurrence. Recurrence after treatment might relate to evidence that suggests sexual transmission is integral to the pathogenesis of bacterial vaginosis, which has substantial implications for the development of effective management approaches.

Lastly, STIs in men who have sex with men have increased since the late 1990s. We discuss the contribution of new biomedical HIV prevention strategies and risk compensation.

Overall, this Commission aims to enhance the understanding of some of the key challenges facing the field of STIs, and outlines new approaches to improve the clinical management of STIs and public health.

In the latest issue of the Sexually Transmitted Infections, Phillip Hay and colleagues in the UK report on a prospective study of female students attending 11 universities and 9 further education colleges in London.

At the start, the students were asked to fill a questionnaire and provide a self taken vaginal sample for infection screening. After 12 months, they were assessed for pelvic inflammatory disease (PID), a condition that can lead to infertility and other complications.

PID was found in 1.6% of the particpants. Unsurprisingly the strongest predictor of PID was the presence of Chlamydia trachomatis at the first visit (relative risk (RR) 5.7).

However, adjusting for this, the authors reported that significant predictors of PID were ≥2 sexual partners (RR 4.0) or a new sexual partner during follow-up (RR 2.8), and age <20 years (RR 3.3). Somewhat surprisingly recruitment from a further education college rather than a university also increased the relative risk of PID 2.6 fold, perhaps reflecting different health protection behaviors (eg condom use) between the two groups.

The study concluded that in addition to known risk factors such as multiple or new partners in the last 12 months and younger age, attending a further education college rather than a university were risk factors for PID.

They recommended that sexual health education and screening programs could be targeted at these high-risk groups.

On May 8 2014 the UK Court of Appeal dismissed the appeal of David Golding against a 14 month prison sentence for transmitting herpes to his partner.

An Editorial in the BMJ by Emily Clarke an colleagues highlights the numerous and complicated issues that arise from this verdict including:

what constitutes grievous bodily harm,

how you determine that sexual transmission has occurred,

how serious is herpes infection, and

what this judgement means both for health care workers who advise and inform patients on the risks of transmission and on the infected individual and their duty of informing all partners of potential risk of transmitting an infection even during asymptomatic shedding.

The Editorial correctly highlights the dangers of criminalizing sexually transmitted infections and the various problems that arise from this judgement which was based on a law passed 170 years ago addressing totally unrelated issues and at a time when STI’s were not understood as they are today.

Bacterial vaginosis (BV) is the commonest vaginal infection seen in women. The Centre of Disease Control (CDC) has recently updated its fact sheet on this common condition.

In summary

BV is linked to an imbalance of “good” and “harmful” bacteria that are normally found in a woman’s vagina. Having a new sex partner or multiple sex partners and douching can upset the balance of bacteria in the vagina and put women at increased risk for getting BV.

BV can cause some serious health risks, including:

Increasing your chance of getting HIV if you have sex with someone who is infected with HIV;

If you are HIV positive, increasing your chance of passing HIV to your sex partner;

Making it more likely that you will deliver your baby too early if you have BV while pregnant;

Bacterial vaginosis (BV) is a common condition in women presenting as a malodorous vaginal discharge. The smell is often worse after sex and arround the menstrual period. Occasionally there is an associated itching or burning sensation although most women with BV only have the discharge. BV can also be detected in women who are totally symptom free.

BV is caused by an imbalance of the normal vagina flora and its mechanism remain poorly understood. An updated review by the Centre for Disease Control (CDC), USA confirms a commonly observation that BV follows sexual intercourse with a new partner and multiple partners as well as vaginal douching.

BV, itself an benign though troublesome nuisance is associated with increased risk of a number of infections or conditions:

Having BV can increase a woman’s susceptibility to HIV infection if she is exposed to the HIV virus.

Having BV increases the chances that an HIV-infected woman can pass HIV to her sex partner.

Having BV has been associated with an increase in the development of an infection following surgical procedures such as a hysterectomy or an abortion.

Having BV while pregnant may put a woman at increased risk for some complications of pregnancy, such as preterm delivery.

The bacteria that cause BV can sometimes infect the uterus (womb) and fallopian tubes (tubes that carry eggs from the ovaries to the uterus). This type of infection is called pelvic inflammatory disease (PID).

Pregnant women with BV more often have babies who are born premature or with low birth weight (low birth weight is less than 5.5 pounds). Pregnant women who have had previous premature of low birth weight babies should be tested and treated for BV in third trimester regardless of symptoms.

Trichomonas vaginalis (TV) is the most prevalent curable sexually transmitted infection (STI) globally. Yet at least 80% of TV infections are asymptomatic, though even asymptomatic infections are a public health concern.

In addition to the risk of transmission to sex partners, TV infection has been associated with as much as a 2.7-fold increase in the risk of HIV acquisition, a 1.3-fold increase in the risk of preterm labour, and a 4.7-fold increase in the risk of pelvic inflammatory disease.

A recent review in the journal Sexually Transmitted Infections (STI) highlights the current knowledge of the global epidemiology of TV infection. These include sex differences in the incidence and prevalence of infection, and the potentially important role of female sex hormones, and the menstrual cycle in mediating TV susceptibility and natural history.

WHO has estimated that over half the 248 million new TV infections each year occur in men. By contrast, 89% of prevalent TV cases are found among women. Biological differences between the sexes contribute to these striking differences between men and women.

There has also been an increased understanding of the mechanisms underlying resistance to metronidazole – the current sole drug available to eradicate the organism.

Recent innovations in detection, including the availability of nucleic acid amplification tests (NAATs), have improved our understanding of the natural history of TV infections. These innovations and our increased understanding of this common sexually transmitted infection should help us combat the global epidemic in TV.